ERAS pathway can cut postdischarge opioid use

JACKSONVILLE, FLA. (FRONTLINE MEDICAL NEWS) – An enhanced recovery protocol for colorectal surgery patients was implemented to not only limit in-hospital opioid use, but also to reduce postdischarge opioid prescriptions.

The results of the enhanced recovery after surgery (ERAS) study were reported at the Association for Academic Surgical/Society of Academic Surgeons Academic Congress by Kathryn Hudak, a fourth-year medical student at the University of Alabama at Birmingham (UAB).

“In surgery we know that opioids are necessary to control postsurgical pain, but their availability certainly introduces the possibility for misuse and abuse,” said Ms. Hudak. In 2015, the division of gastrointestinal surgery implemented the ERAS pathway to improve recovery and reduce opioid use among surgery patients.

The researchers compared outcomes of 197 patients in the ERAS database at the institution who had colorectal surgery in 2015 with 198 patients who had surgery in 2013 and 2014 before the ERAS protocol was put in place.

Overall, the ERAS program had successes. “Using ERAS, we have shown a reduction in hospital length of stay and reduction in postoperative complications, [and] a reduction in hospital costs without any increase in readmissions or mortality,” Ms. Hudak said. Average length of stay decreased by 2 days and postoperative complications by 30%, study results showed.

“One purpose of ERAS is to control pain with as little need for opioids as possible,” she said. Pain management in the ERAS protocol used at UAB involved celecoxib, gabapentin, and acetaminophen before surgery; ketorolac and lidocaine during the operation; and alternating acetaminophen with other nonsteroidal anti-inflammatory drugs and oral oxycodone as needed after surgery. “If ERAS uses multimodal analgesia to avoid opioid use in the hospital, we wanted to know if we could see any effect in the use of opioids outside of the hospital,” Ms. Hudak said.

ERAS patients had more minimally invasive surgery (43.4% vs. 32.5%), more ostomies (38.9% vs. 25.9%), and lower rates of baseline opioid use (15.2% vs. 29.4%). So these patients would be expected to have a lower need for postdischarge pain medications.

For the study overall, 89.6% of patients in both groups were discharged with an opioid prescription but, Ms. Hudak said, “more of our ERAS patients were discharged without a prescription for an opioid – 14.1% vs. 7% in the pre-ERAS patients. “In our ERAS patients, we found a significantly different makeup in those discharge medications,” she said. “Many more patients were discharged on tramadol or a combination of tramadol and oxycodone or hydrocodone – again, using more of those low-potency opioids.”

The study revealed one unexpected finding, Ms. Hudak said. “We found that ERAS patients had a higher number of pills prescribed and OMEs [oral morphine equivalents], and we were surprised by this because we were expecting the opposite,” she said. Among those discharged with opioids, ERAS patients had an average oral morphine equivalent of 403 and 60.6 pills vs. 343 OMEs and 46.9 pills pre-ERAS (P less than .03). However, per-pill OME ratios were lower for the ERAS group: 6.9 vs. 7.6, Ms. Hudak said.

The study also followed up with patients a year after discharge, and found that 34% of ERAS patients needed an additional prescription while 44% of pre-ERAS patients required additional high-potency opioids, Hudak said.

“ERAS does seem to modify postdischarge opioid utilization, but we definitely need to work toward better standardization of opioid prescribing,” Ms. Hudak said. The UAB has since implemented a standardized protocol for residents to prescribe opioids after surgery based on a patient’s risk for postoperative pain, she said.

Ms. Hudak and her coauthors had no financial relationships to disclose.

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